Nokea
The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take?
- A. Obtain baseline platelet count
- B. Verify ABO compatibility
- C. Infuse over two to four hours
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: FFP requires ABO compatibility verification to prevent transfusion reactions, as it contains plasma proteins and antibodies. Platelet counts are irrelevant to FFP, infusion time is typically 30–60 minutes, and an ECG is not routinely required.
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If the client develops lower abdominal pain after a cystoscopy, the nurse should instruct the client to do with following?
- A. Apply an ice pack to the pubic area.
- B. Massage the abdomen gently.
- C. Ambulate as much as possible.
- D. Sit in a tub of warm water.
Correct Answer: D
Rationale: Sitting in warm water can soothe bladder irritation and relax pelvic muscles, alleviating lower abdominal pain post-cystoscopy.
The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD?
- A. Hairy legs
- B. Mottled skin
- C. Pink, cool skin
- D. Warm, moist skin
Correct Answer: B
Rationale: Mottled skin (livedo reticularis) is a common manifestation of PVD due to poor perfusion, causing irregular skin discoloration. Hairy legs, pink cool skin, or warm moist skin are not typical; PVD often presents with hair loss, cool, pale, or cyanotic skin.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
- A. The client can walk throughout the entire hospital with a walker.
- B. The client can walk the length of a hospital hallway with minimal pain.
- C. The client has increased independence in transfers from bed to chair.
- D. The client can raise the affected leg 6 inches with assistance.
Correct Answer: C
Rationale: Increased independence in transfers is a realistic and measurable goal for discharge.
The nurse observes that a client's ileostomy output is green and watery. Which action should the nurse take first?
- A. Notify the physician immediately.
- B. Document the finding as normal.
- C. Increase the client's fiber intake.
- D. Administer an antidiarrheal medication.
Correct Answer: B
Rationale: Green, watery output is normal for an ileostomy, especially early post-surgery, and should be documented. Notifying the physician, increasing fiber, or giving antidiarrheals are unnecessary unless other symptoms arise. CN: Physiological adaptation; CL: Synthesize
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?
- A. Remove all the food.
- B. Remove the coffee.
- C. Remove the toast, butter, and marmalade only.
- D. Substitute vegetable juice for the orange juice.
Correct Answer: B
Rationale: Coffee should be removed because caffeine can alter brain wave activity, affecting EEG results. The other foods do not typically interfere with the test.